We presented a case, sixty-six-year-old woman, who had been treated with large allograft for severe structural deficiency about the hip joint associated with prior failed total hip replacement. The acetabulum and a part of the femoral neck were reconstructed with frozen massive allografts. Partial weight bearing was started at three months postoperatively. A year after surgery loosening and proximal migration of the acetabular component were revealed radiografically. We are considering the additional operation for her hip pain.
Judet cementless hip prostheses were performed at the Yamaguchi Central Hospital in 167 hips during the period from 1976 to 1987. Revision surgery was undertaken for socket loosening in nine patients, stem breakages in three. Statistical analysis was performed using the general Wilcoxon test, and the prosthesis survival was estimated using a nonparametric estimation of survival. Total hip arthroplasty may fail by a variety of mechanisms. Failure may be related to prosthetic design, and setting angle of inserted socket. Setting angle of the socket was clssified into three groups. Setting angle was less than 45 degrees in group 1, from 45 to 60 degrees in group 2, and more than 60 degrees in group 3. There was no significant difference in prosthesis survival probabilities among three groups. Robert Judet made socket design better in 1980. There was significantly improved (P<0.001) prosthesis survival in the new type in comparison to the old type. It was suggested that improve of the socket was significant.
Five-12 year results of 72 total hip arthroplasties were reviewed with emphasis placed on the radiologic evaluation of the acetabular and femoral components by Charnley' s method at an average follow-up period of 7.7 years. Their mean age at surgery was 57.4 years (range, 30-76 years). About sixty per cent of the sockets had no cement-bone demarcation and 22.2% had a small line in the upper outer quadrant of the socket. In ten hips (13.9%), socket demarcation was complete, and in three cases (4.2%), migration was identified. The mean rate of socket wear that was followed up for more than nine years was 0.06mm per year. Fracture of the femoral cement was found in 10 hips (13.9%), and demarcation around the femoral bone-cement interface in 10 hips. Eight hips (11.1%) were judged to have femoral loosening. The revision rate of the socket was 2.8% and of the femoral prosthesis was 5.6%.
In order to know the developmental pattern and the role of the osteophytes in the osteoarthritic femoral head, surgically resected 71 femoral heads were cut into serial slices of 7 to 10mm thickness in a coronal plane and each central slice was radiographed. The shapes of the osteophytes were classified into three types, and characteristic features of the structure of the bone trabeculae in each type were studied. Type I: Small osteophyte. No trabeculae are found in the osteophytes. Type II: Pendant-like osteophytes. The trabeculae run perpendicular to the joint surface. Type III: Elephant's trunk osteophyte. The course of the trabeculae is not uniformal but rather complicated. The osteophytes would develop from type I to type II in most of the cases as the stage of osteoarthritis advances. In this process of the development, some osteophytes could function as the weight bearing area in the hip. This will be one of the significant roles of the osteophytes. However, this situation does not always continue permanently. The significans of type III of unique enlargement was difficult to evaluate from this series.
The incidence of avascular necrosis in Hand-Schüller-Christian disease is very low. This paper reports one patient with avascular necrosis of the femoral head in Hand-Schüller-Christian disease. The patient was a 34-year-old woman, admitted to our hospital with a chief complaint of pain at her left hip. Roentgenograms revealed the collapse and deformity of the left femoral head and a round lytic lesion in the central area of the femoral head. The single-assembly total hip replacement was performed in April, 1986. The histological findings of the femoral head showed the subchondral bone necrosis and the typical cellular composition of histiocytes with eosinophils in the central lesion of the femoral head.
Femoral neck fracture following aseptic necrosis of the femoral head is rarely reported. We have experienced two such cases and reported here. Histologically, the extracted femoral head had wide necrotic area with process of bone resorption and formation being present partially. The mechanism of the fracture was suggested that the widened necrosis of the femoral head caused physical stress upon the cervical region resulting in fracture.
Rapidly Destructive coxarthrosis (RDC) has been reported these twenty years by a lot of authors. According to some papers, clinical findings of RDC has not changed so much and histopathological findings are now in consistent with femoral head necrosis, but X-ray findings of RDC at its initial stage and late stage are not in total accord. We experienced two cases that seemed to be RDC in the last six years. It might be said that nature of RDC is avasculan necrosis occurring with proliferation of sinovium at early stage and besides mechanical and immunological factors, bone fragments and crystals freed from exposed subchondral bone might accelerate joint damage by interacting with sinovium and causing release of destructive factors as well as synovial proliferation. In addition, we studied two cases of osteoradionecrosis that reached similar advanced stage clinically and radiologically to that of RDC.
We reported clinical, radiological and histological studies of 30 patients (33 hips) with rapidly destructive coxopathy (RDC), and also histological study of the acetabulum of 16 hips. From the radiological findings, we classified RDC into three types. Type I is the most typical one that starts from a normal hip and later shows subluxation. Type II ends without subluxation. Type III starts from secondary coxarthrosis. From the histological findings, we classified them into avascular necrosis and osteoarthritis. Rate of Avascular necrosis was 75% in Type I, 40% in Type II, and 0% in Type III.
We treated a case of the arteriovenous malformation associated with neurofibromatosis. The case was a 41-year-old female who was admitted to the hospital on july 19, 1986, complaining of dysphasia and monoplegia of the right upper extremity. X-ray findings of the cervical spine showed severe kyphoscoliosis. The AVM was suspected by the angiography of the right vertebral artery. A myelography showed no block. The AVM was treated by clipping of the right vertebral artery at the level of T1 and C2 and the cervical spine was treated with anterior fusion at the level of C2 to C6. The dysphasia disappeared after the clipping of the AVM. Four months later from anterior fusion the monoplegia was gradually reduced.
This prospective study was designed to evaluate electrophysiological changes in the peripheral nerve, especially in the median nerve at the wrist, of the patients with a cervical lesion. We examined the motor nerve conduction velocity of the median nerve at the forearm, the amplitude of the M wave recorded from abductor pollicis brevis muscle and the distal motor latency of the median and ulnar nerve. The distal motor latency of the median nerve was significantlly prolonged in the patients with cervical lesions compared with the normal control group (p<0.01).
We have once reported about the isometric strength of the neck muscles in these series. Here we again attempted to analyse the relation between the clinical symptoms and the strength of the neck muscles in the groups with cervical disorders and to show the postoperative changes of the strength. We measured the isometric strength of the neck muscles for 41 cases with cervical disorders (CSM-21 cases, CSR-7 cases, OPLL-13 cases) and 120 control cases. CSM group and OPLL group showed less power in extension than presenile control group. The group of cases with anterior interbody fusion showed generally less power than the group of posterior decompression at the postoperative time of 1-2 months (mean 6 weeks), while at the late postoperative time (3-6 months, mean 15 weeks), loss of neck extension power was persistently noticed in the group of posterior decompression.
Traction of cervical spine as conservative treatment have been a common treatment of cervical spine lesion for many years. Glisson's sling is applied to the chin and occiput, therefore the lesion of gingiva and temparomandibular joint with continuous cervical traction are unavoidable. Accordingly we carried off a chin piece from the Glisson's sling, and attached a frontal head bandage to the posterior strap. Our improved cervical traction sling makes the chin free.
Thirty-one cases of cervical myelopathy treated by skull traction were studied to clarify its clinical effect. The results were as follows. 1. Clinical effects of skull traction for cervical myelopathy were found in 22 of all 31 cases and the results of that were 7 cases in excellent, 16 cases in improved, 6 cases in unchanged and 2 cases in worsened. 2. In most cases the effects of skull traction appeared in a few days and lasted for 2 to 3 weeks. 3. The most improved symptom was gait disturbance, and urinary dysfunction was scarcely improved. 4. The results of skull traction were not always satisfactory in terms of ADL except for 2 cases of cervical disc herniation, and 26 cases needed surgical treatment eventually. 5. The results of traction were not influenced by age, severity of myelopathy, diameter of spinal canal, range of motion and existence of dynamic canal stenosis except for duration of symptom. 6. Postoperative results were in proportion to effects of skull traction.
Since 1979, 94 patients of cervical spinal disease have been operated on in our clinic, of which 9 cases (9.6%) were reoperated. These were 6 males and 3 females, ranging in age from 34 to 64 years (mean, 50 years). The interval between the first and the second operation ranged from a day to 7 years and 5 months with an average being a year and 4 months. The causes of reoperation were as follows: 1) poor fusion technique (4 cases), 2) existence of spinal canal stenosis (2 cases), 3) insufficient anterior decompression (a case), 4) unrecognization of responsible focus (a case), and 5) growth of other level (a case).
Recently, the surgical results for cervical spondylotic myelopathy are gradually improving, but in some cases multiple operations are required. We have reviewed 45 patients who required multiple operations of the cervical spine. For the first operation, forty-three patients were treated by anterior interbody fusion by the Cloward's or Smith-Robinson's technique (AF) and 2 (athetoid CP) by extensive laminectomy (L). For the second operation, twenty-seven patients were treated by AF, 15 by L and 3 by enlargement of cervical spinal canal (E). Among them, we have carried out the third operation on seven patients (AF: 2, L: 2, E: 3). The causes of multiple operations are recurrence at the other disc level, mischoice of surgical procedures, non-union, unexpected postoperative OPLL, failure of decion of surgical site and athetoid CP. We must decide appropriate surgical procedures and surgical site for each patient, referring to the clinical symptoms, roentgenograms and myelography findings.
The purpose of this paper is to describe the factors from a viewpoint of reversibility of spinal cord, which infuluence the postoperative result of cervical spondylotic myelopathy. In this report 250 patients were studied. There were 176 males and 74 females. The results were divided into 6 groups including 5 groups described in the past and a additional group in which the postoperative result was improved 100 percent efficaciously according to the Japanese Orthopaedic Association's criteria. Each group was evaluated with regard to 7 major factors, age, sex, the duration of symptoms, the JOA score at admission, antero-posterior diameter of the cervical canal and so on. Following results were obtained. 1. The results were closely Related with the factors of the duration of symptoms, age, the JOA score at admission, the antero-posterior diameter of the cervical canal in oder. 2. Taking in a new group in which the postoperative result was Improved 100 percent effectively was valuable because the author could determine which spinal cord was clinically reversible or not.
Eighteen cases of cervical myelopathy due to OPLL induced by minor trauma were studied, which consisted of 16 males and 2 females. Their ages ranged from 41 to 76 years old (average; 56 years old) at the time of operation. The follow-up periods were more than 1 year and up to 15 years (average; 7 years). The overall results were not satisfactory comparing with those of cases not-induced by trauma; that is, excellent and good results were obtained in 39% of the cases at the time of discharge, and in 39% at the time of follow-up study. Based on our follow-up results we propose that the plan of operative therapy of trauma-related myelopathy is as following: for the cases with symptoms of myelopathy which appear some time after improvement of traumatic cord lesion, ordinary therapeutic regime can be taken and satisfactory results are obtained, however, for the cases with incomplete recovery from traumatic cord lesion, operation is one of the choice when severe canal stenosis exists.
Thirty-five patients with cervical OPLL after anterior decompressin surgery were followed up, and fifteen of them showed radiologically recognized reossification of OPLL at the ossification-removed levels. They were examined by CT scanning. The CT findings of ossification were classified into four types by the manner of reossifications. The etiology of reossification is unknown.
A roentgenological study was carried out in 65 families of OPLL cases. The number of family members studied was 289 and 65 were OPLL patients. In 11 families, all members within 2 generations were studied and their family trees were made. The number of relatives having OPLL was 51 (22.8%), of which 47 were older than 40 years old. The other ossification in ligaments of the spinal canal such as OYL, OALL, OSSL, Barsony was seen in 10-30% in relatives. We studied the type of heredity of OPLL by the a-priori method and the proband method, which suggested that the type of heredity was dominant inheritance, but was under the influence of the aging and circumstance.
Our patient, an 8-year-old girl, who was formerly diagnosed as lumbar disk herniation for her gait disturbance, showed the nidus at the lamina of the first sacrum. Surgical excision of this nidus was carried, and she was completely relieved from her complaint. We report this rare case of osteoid osteoma of the sacrum.
We have experienced two cases of proximal neurogenic muscular atrophy with low back pain. A 56-year-old woman visited our hospital for low back pain and muscle weakness of lower extrimities. After various investigations, we made a diagnosis of Vulpian-Bernhardt type SPMA. A 26-year-old man has been followed up as Kugerberg-Welandar disease. Recently he has begun to complain of low back pain. In two cases, lumbar lordosis is increased due to muscle weakness of limb girdle muscles. No organic changes are revealed in their lumbar spines. It is suggested that their low back pain is caused by malposture or increased lumbar lordosis. Application of corset was effective for their treatment.
The relationship between the abnormalities of the posterior elements and anterior elements in lumbosacral transitional vertebrae, and then the relationship between disc degeneration and lumbosacral transitional vertebrae were investigated. The modified Jinnaka's classification for the abnormalities of posterior elements and the modified igh's classification for the abnormalities of anterior elements were employed for this purpose. Of 597 patients with low back pain, 82 patients (14%) presented the posterior abnormalities and 90 patients (15%) presented the anterior abnormalities. Ninety% of type I of posterior abnormalities showed normal disc in anterior, whereas only 4% of type II-IV showed normal disc. Ninety-four% of type III of posterior abnormalities had type I and type II (and III) of anterior abnormalities which were thought typical fixed transitional vertebrae. It presents a greater than normal incidence of the disc degeneration, especially posterior slip at the level of just above the lumbo-sacral transitional vertebrae.
Ossification of the posterior longitudinal ligament (OPLL) of the lumbar spine was studied. There were thirty-one cases consisting of 12 males and 19 females. Their ages ranged from 37 to 76 years old (average; 55 years old). The types of ossification were classified to 25 cases of localized type and 6 cases of continuons type. We diagnosed clically and radiologaically 7 of them as symptomatic OPLL and others as asymptomatic. Six cases of symptomatic OPLL were operated and excellent results were obtained in all cases. To assess the symptoms due to OPLL, we attempted to compare the symptomatic OPLL with asymptomatic one. In spite of their existence of OPLL, it may or may not have clinical symptoms and signs. Therefore careful attention must be taken to observe the condition.
A rare case of spinal dysraphism of which symptomatic onset had been in adulthood was reported. A thirty-Seven years old male had consulted our out-patient service with complaint of dysesthesia in his left leg. Physical examination revealed a small dimple of his skin, hairly patch and lumbosacral lipoma on his back. Plain X-ray showed spina bifida from the fourth lumbar vertebra to the sacrum. During observation at the out-patient service, dysesthesia was deteriorated up to the L4 dermatome. Spinal exploration was noted to continue deeply into the subarachnoid space by a fibrous band, and to connect to the intraspinal lipoma on the low placed connus medullaris. Conus medullaris and cauda equina were seen to be pulled dorsally by the fibrous band, which was cut to free spinal cord from tension. Postoperatively dysesthesia in the leg improved.
In 1984 Cotrel and Dubousset had designed a new method of instrumentation aimed at obtaining a surgical fixation of the scoliotic curve. This instrumentation system provided better rigid fixation and allowed correction of rotation. Furthermore, it provided wide application for other spinal disorders. Since 1986, we applied this system to lumbar disorder accompanied with instability, Charcot spine and lumbar caries. In 7 cases, it was used for internal fixation after posterior decompression. In a case of lumbar caries, this instrumentation was used for internal fixation after anterior procedure. This method gave best results for rigid fixation and spinal alignment in all cases. No failure of instrument was observed at postoperative course. We recommend this method as instrumentation of the lumbar disorder accompanied with instability.
We analysed the causes of multiply operated back in 31 cases treated with salvage operation in our center and evaluated the postoperative results. The initial diagnoses were lumbar disc herniation in 23, lumbar canal stenosis in 2, spondylolysis in 2, spondylolytic spondylolisthesis in 3, lumbar disc degeneration in one. The main causative factors of multiple operations for a lumbar disc herniation were root fibrosis, symptomatic disc degeneration, recurrent herniation, adhesive arachnoiditis. There was no correlation of the clinical results of salvage operations with the causative factors. After posterior spinal fusion for salvage operation leg pain well improved in most patients, but, relief of low back pain was not so good. After anterior spinal fusion, leg pain and low back pain well improved in almost all patients.
The lateral cervical roentgenogram is a useful guide in evaluating the bony and soft tissue relationships of the neck. Particularly, the measurements of the cervical soft tissue width are extremely important in determining the presence or absence of cervical spine injury. We therefore established the criterion of prevertebral soft tissue thickness. To determine the normal appearance, we examined 100 adults without detectable abnormalities in our clinic. We measured 248 cases of the cervical injury that had had operative treatment in our center. There were apparent differences in the results between these two groups. The prevertebral soft tissue width was measured at the level of the anteroinferior border of the second and sixth cervical vertebral body, the former is retropharyngeal space and the latter is retrotracheal space. This point was chosen because it was above the pharynx and the trachea, easy to determine, and free from conflicting shadows. It is suggested that measurments for the retropharyngeal space greater than 4mm, and measurments of the retrotracheal space greater than 15mm, should be indirect evidence of cervical spine injury.
Posterior cervical fusion with a Luque square rod was performed in four cases of traumatic fracture-dislocation of the cervical spine. Good stabilization and alingnment of the cervical spine were achieved by this method. The postoperative management was easy with early rehabilitation. It is concluded that this operation is a better way for the treatment of unstable cervical spine.
A case of neglected rupture of the patellar ligament is presented. A twenty-one-year-old man visited our clinic with giving way and extension lag of the right knee. Examination revealed scar at the infrapatellar region of the right knee and loss of ligamentous structure. We recognized rupture of the patellar ligament, and reconstructed it with pediculated iliotibial tract augmented by McLaughlin's method. One year after operation, his right knee has got full range of motion and normal muscle power, and the patient has recovered to work.
A group of 10 patients with unstable knees due to a combination of a medial meniscal tear with a rupture of the anterior cruciate ligament was studied to assess the effects of treatment. The results were assessed both subjectively and objectively. It was concluded that in patients with this combined lesion, it would be preferable to perform anterior Cruciate reconstruction using a bone-tendon-bone graft at the same time as the meniscal suture or meniscectomy.
Commercially available knee braces, as a means of providing knee stability for the nonoperative treatment and following surgical repair or reconstruction of the cruciate ligament injuries, fall short of providing anteroposterior stability with knee flexion. One of the major problem area is that a strap system becomes lax with knee flexion. We have developed a knee brace which has single or double coil-spring traction systems minimizing the abnormal sagittal deviation between femur and tibia within the range of knee motion. This new brace was introdused and has been used in 33 patients with ACL or PCL injuries. Radiological assessment of two cases of single coil-spring traction system demonstrated reduction by half of sagittal laxity. Three patients with ACL injuries were evaluated betore or without surgical treatment, and they were reduced in pain, episodes of giving way, and performance of down stairs, and their extension/flexion torques evaluated by Cybex II were improved by the brace. Other patients could not be evaluated objectively, because of short postoperative periods and influence by operative methods. Early rehabilitation, however could be possible with this brace.
An operation is described in which the semitendinosus and gracillis are used to serve as an intraarticular graft for the controll of acute and chronic posterior instability of the knee. The procedure was done in ten patients. Eight patients were reviewed, with a follow-up of eighteen to forty-two months. At follow-up, instability was improved in seven patients and the results were rated as good or excellent in six of them. One failure was due to severe damage of posterior capsule and articular cartilage. The ROM of the knee were better than we expected. This operation can be recommended to the young generation.
A patient with ankylosis of the right knee was referred to our hospital. The patient was found to have had reconstructive surgery of the posterior cruciate ligament 7 months previously. He underwent manipulation and arthroscopic treatment without improvement of 40 degrees of flexion deformity. Posterior release with excision of the anterior and posterior cruciate ligament was carried out in our hospital. Calcification and ossification were found in the proximal part of the anterior cruciate ligament, which was considered to be a cause of the restriction of knee extension. A good result was obtained by using a continuous passive motion machine and sponge traction immediately after the operation. Range of motion was from 0° to 150° of flexion one year after the surgery.
Arthroscopic reconstruction of the anterior cruciate ligament with Leeds-Keio artificial ligament was performed on 10 cases between July 1986 and November 1986. The average age of the patients at the time of surgery was 20 years. Almost all patients showed good clinical results at follow-up of more than 6 months.
Sixteen cases of arthroscopic ACL reconstruction were reviewed, Nine cases were followed for more than 6 months postoperatively. Loss of range of knee motion was none or minimal except for one case. Instability was found in 8 of 9 cases, which was so high in frequency that authors reviewed postoperative roentgenograms of those cases and discussed on ligament placements.
This report is an atempt to investigate the results of three operated cases which had been untreated for the anterolateral rotatory instabilities of the knee. The roentgenograms of these cases revealed slight joint space narrowing before the operation. The first, case, a 27-year-old female with normal leg alignment, showed satisfactory results after four years follow-up period inspite of roentgenographic deterioration. The second case, a 31-year-old femamale with varus deformity, had the additional osteotomy below the tibial tuberosity becaus of pain and swelling two years later. The third case, a 26-year-old feamale with varus deformity, had been complaining of occasional pain and swelling of the operated knee for three years after the operation.
We reported two cases of excessive lateral pressure syndrome (ELPS) that were suggested by the X-rays. The two cases were a 15-year-old and a 17-year-old high school students. They both complained of continueing and increasing knee pain. The roentgenograms demonstrated an elongation of the lateral pole of the patella in one case, and ossification in the lateral retinaculum in the other. These findings were considered to be suggestive findings of ELPS.
The case was a 32-year-old man who complained of left gonalgia and giving way. A small nodule was palpable at the lateral side of the patella and painful crepitus occurred at 45 degree of knee flexion Arthroscopic findings revealed that protruding lateral adipososynovial fringe was caught at PF-joint. After arthroscopic resection, pain decreased.
The case reported here was a 17 years old man. He had the mild hemophilia with factor 8th level of 11% and was recently complicated by a traumatic false aneurysm of the descending genicular artery. Hemophilia is a hereditary bleeding state due to deficiency of an essential blood clotting factor called factor 8th. The disorder is generally characterized by the spontaneous recurrent bleeding into muscles and joints which occurs since infancy. However, the mild hemophilia with factor 8th level of over 5%, as has been observed in our case, is difficult to be diagnosed because it shows no abnormal bleeding on most occasions except for surgical procedures or trauma.
From December 1981 to August 1986, arthroscopic meniscectomy of 147 joints in 139 cases was performed (medial normal type: 59, lateral normal type: 33, lateral complete discoid: 49, lateral imcomplete discoid: 52). Thirty-four cases of 58 normal type medial meniscus injury (58.6%) had no obvious history of trauma prior to the onset of symptoms. The most frequent configuration of the tear was longitudinal tear on lateral menscus and posterior flap tear on medial meniscus. Normal type meciscus injury with no history of trauma may be based on a degenerative aging process, but this injury was observed in younger people who were not involved in osteoarthritic changes of articular cartilage. This posterior type of tear had resemblance to the degenerative tear of posterior segment in osteoarthritis and was thought to be one of eary stage of medial type osteoarthritis.
Because of the variety and concomitant ligamentous damage or meniscal lesion, tibial plateau fractures are notorious for the poor resulted intra-articular fracture. Accurate diagnosis of associated intraarticular pathology, reduction of displaced fragments, adequate stabilization, early motion, and delayed weight bearing are necessary for the good results. Arthroscopic managements for the fractures were reported in a few cases of osteochondritis dissecans and less of the tibial plateau fractures. We performed the arthroscopic management on 6 cases of tibial plateau fractures in 15 cases. Arthroscopy has the advantages of accurate reduction and rigid fixation without extensive operative exposure. In addition, it allows thorough lavage, removal of loose fragments, and accurate diagnosis of associated intraarticular pathology. Since extensive exposure is avoided, rapid recovery with reduced pain and early full range of motion is achieved in patients managed arthroscopically.
We investigated 10 cases treated by Judet's mobilization procedure which resulted in contracture because of the femoral shaft fracture (5 cases), supuraepicondyle fracture of the femur (1 case), epicondyle fracture of the femur (3 cases) and femoral nerve palsy (post ten-don-transfer-operation, 1 case). An average post-operative follow-up period was 5yrs. and 6mos. At follow-up examination, they had almost the same value of the knee flexion as those obtained during the operation. The factors that related to the results were suggested to be the value of the knee flexion during operation and the operation time.
Since May, 1986, Whiteside OrthoLoc Total Knee System was used in Twenty cases. Eleven cases (12 knees) who had had total knee replacement were followed-up for more than 3 months (ave. 6.7 months) after surgery. Nine cases (10 knees) had osteoarthritis (OA) and Two cases (2 knees) had rheumatoid arthritis (RA). Ten of the cases were female and 1 was male whose average age was 63.5 years. Using the criteria described by three universities, the clinical results were evaluated. The score was improved from 44.9±4.9 to 79.5±2.4 and roentgenographical results showed that FTA were improved from 187.8°±4.9° to 174.1°±2.6°. Good results were obtained in all cases, however, in some cases the small-size component was relatively small especially in its transverse diameter and it should be replaced in the near future.
Ipsilateral hip and femoral shaft fracture is rare and their treatment is various. This time, we experienced two such cases caused by traffic injury. We operated one case by Hagie pin and K-U plate and another case by Hagie pin and Ender Nail. Good radiological results were obtained in both cases.
Ninety patients with a trochanteric fracture of the femur were treated by Ender-pin fixation during a period from 1980 to 1986 inclusive. Among the 90 patients, there were 17 men and 73 women. The age range was from 36 to 99 years. Most patients sustained their fractures from a simple fall on the floor or the ground. Of the 90 fractures, 51 were classified as stable and 39 as unstable. Our study was undertaken to evaluate these patients with particular regard to shortening of the leg.
We reported 6 patients of fracture of the upper third of the femoral shaft. In these cases, we used two stacked cloverleaf nails to fill the canal. All the patients obtained solid union with good functional results. Two stacked cloverleaf nails can be a useful method for the fracture of the upper third of the femoral shaft.
168 fractures of the shaft of the femur and tibia operatively treated by various methods have been studied to determine whether these treatments were justified. Especially we compared closed Ender nailing, closed Kuntscher nailing and plating in terms of bone healing. The results are as follows. Generally there were little differences between three methods. But in middle-third of the shaft of the femur, the fractures treated by plating had a tendency to slightly delay in union. We consider it important to select the right method according to each case.
We treated 24 open tibial fractures over a five-year period. These cases were classfied according to the type of the wound and the grade of the fracture, and treated individually according to the classification. There was no infection. The prevention of infection is most important in the treatment of open fractures.
Needless to say, the most important problem in open fracture is infection. When the laceration of skin or muscle is severe, and when the fracture is comminuted, we often have to use external fixation method. Before 1985, we used plaster cast or external fixation using methyl methacrylate. But, since 1985, we have used dynamic axial fixator (D. A. F.). It is easy to put it on a patiant. Little discomfort has been complained by the patiants. However, there was a case of re-fracture after removal, of D. A. F.. Accordingly, we studied advantage and disadvantage of D. A. F. and the time of its removal, comparing with the method using methyl methacrylate.